5000 W Clearwater Ave. Kennewick, WA 99336
5097835000
info@cw-dental.com

New Patient Paperwork

  • Info
  • Insurance Info
  • Medical History
  • Notice of Privacy Practices

Personal Information

First Name

Last Name

Soc. Sec#

Birthdate

Gender

Address

City, State, Zip Code

Phone

Email

Emergency Contact

Full Name

Phone #

Responsible Party

Is the Patient a Minor?

Name

Soc. Sec#

Relation to Patient

Other

Birthdate

Address

City, State, Zip Code

Phone

Email

Is the Patient responsible for the billing?

Full Name

Soc. Sec#

Relation to Patient

Other

Birth Date:

Address

City, State, Zip Code

Phone:

Email:

Please Let Us Know

What did you like OR dislike about your previous dentist?

Who referred you to our office? We would like to thank them!

Referred By:

Dental Insurance

Do You Have Dental Insurance

That’s okay! We offer several options that you can use to pay for your treatment: 1.) Cash or Check (receive a 5% discount!) 2.) Credit Cards (We accept all major Credit Cards) 3.) CareCredit Financing Click Below to Continue to Medical History

Primary Insurance Information

Name of Subscriber

Soc. Sec#

Relationship to Patient

Birth Date

Employer

Insurance Subscriber's Information

Address

City, State, Zip Code

Phone

Email

Insurance Company

Group #

ID #

Ins. Co. Phone

Ins. Co. Address

Ins. Co. City, State, Zip Code

Secondary Insurance Information

Name of Subscriber

Soc Sec#

Relation to Patient

Other

Birth Date

Employer

Insurance Subscriber's Information

Address

City, State, Zip Code

Phone

Email

Insurance Company

Group#

ID#

Ins. Co. Phone

Ins. Co. Address

Ins. Co. City, State, Zip Code

Privacy Notice

NOTE: Although dental personnel primarily treat area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

Brief Medical History

Are you under a Physician’s Care now ?

Have you ever been Hospitalized / had Major Surgery ?

Have you ever had a serious Head or Neck Injury ?

Are you taking any Medications, Pills, or drugs ?

Are you on a any sort of Special Diet ?

Do you use tobacco ?

Do you use any controlled Substances ?

Have you ever taken Fosamax, Boniva, Actonel, or any other medications containing bisphosphonates ?

Women: Are You

Are you allergic to any of the following ?

Other:

Do you have or have ever had any of the following ?

AIDS / HIV Positive

Alzheimer's Disease

Anaphylaxis

Have you ever had a serious illness that is not listed above?

Other Ilness

Additional Comments:

Acknowledgment of Notice

We keep a record of the health care services we provide you. You may ask to see and copy that record. You may also ask to correct that record. We will not disclose your record to others unless you direct us to do so or unless the law authorizes or compels us to do so. You may see your record or get more information about it by contacting Dr. Han, Dr. Rose or Dr. Rhoten. Our Notice of Privacy Practices describes in more detail how your health information may be used and disclosed, and how you can access your information.

Do you Acknowledge